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Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI. Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation. In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79-1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89-1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71-1.32; P = 0.84). Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation.

Abstract Background Multidrug-resistant organism (MDRO) infections are associated with high mortality and readmission rates. Infectious diseases (ID) consultation improves clinical outcomes for drug-resistant Staphylococcus aureus bloodstream infections. Our goal was to determine the association between ID consultation and mortality following various MDRO infections. Methods This study was conducted with a retrospective cohort (January 1, 2006–October 1, 2015) at an academic tertiary referral center. We identified patients with MDROs in a sterile site or bronchoalveolar lavage/bronchial wash culture. Mortality and readmissions within 1 year of index culture were identified, and the association of ID consultation with these outcomes was determined using Cox proportional hazards models with inverse weighting by the propensity score for ID consultation. Results A total of 4214 patients with MDRO infections were identified. ID consultation was significantly associated with reductions in 30-day and 1-year mortality for resistant S. aureus (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.36–0.63; and HR, 0.73, 95% CI, 0.61–0.86) and Enterobacteriaceae (HR, 0.41; 95% CI, 0.27–0.64; and HR, 0.74; 95% CI, 0.59–0.94), and 30-day mortality for polymicrobial infections (HR, 0.51; 95% CI, 0.31–0.86) but not Acinetobacter or Pseudomonas. For resistant Enterococcus, ID consultation was marginally associated with decreased 30-day mortality (HR, 0.81; 95% CI, 0.62–1.06). ID consultation was associated with reduced 30-day readmission for resistant Enterobacteriaceae. Conclusions ID consultation was associated with significant reductions in 30-day and 1-year mortality for resistant S. aureus and Enterobacteriaceae, and 30-day mortality for polymicrobial infections. There was no association between ID consultation and mortality for patients with resistant Pseudomonas, Acinetobacter, or Enterococcus, possibly due to small sample sizes. Our results suggest that ID consultation may be beneficial for patients with some MDRO infections.

Population attributable risk percent (PAR%) is an epidemiological tool that provides an estimate of the percent reduction in total disease burden if that disease could be entirely eliminated among a subpopulation. As such, PAR% is used to efficiently target prevention interventions. Due to significant limitations in current Clostridium difficile Infection (CDI) prevention practices and the development of new approaches to prevent CDI, such as vaccination, we determined the PAR% for CDI in various subpopulations in the Medicare 5% random sample. This was a retrospective cohort study using the 2009 Medicare 5% random sample. Comorbidities, infections, and healthcare exposures during the 12 months prior to CDI were identified. CDI incidence and PAR% were calculated for each condition/exposure. Easy to identify subpopulations that could be targeted from prevention interventions were identified based on PAR%. There were 1,465,927 Medicare beneficiaries with 9,401 CDI cases for an incidence of 677/100,000 persons. Subpopulations representing less than 15% of the entire population and with a PAR% ≥ 30% were identified. These included deficiency anemia (PAR% = 37.9%), congestive heart failure (PAR% = 30.2%), fluid and electrolyte disorders (PAR% = 29.6%), urinary tract infections (PAR% = 40.5%), pneumonia (PAR% = 35.2%), emergent hospitalization (PAR% = 48.5%) and invasive procedures (PAR% = 38.9%). Stratification by age and hospital exposures indicates hospital exposures are more strongly associated with CDI than age. Small and identifiable subpopulations that account for relatively large proportions of CDI cases in the elderly were identified. These data can be used to target specific subpopulations for CDI prevention interventions.

Background The postpartum period provides an opportunity for birthing people with opioid use disorder (OUD) to consider their future reproductive health goals. However, the relationship between the use of medication for opioid use disorder (MOUD) and contraception utilization is not well understood. We used multistate administrative claims data to compare contraception utilization rates among postpartum people with OUD initiating buprenorphine (BUP) versus no medication (psychosocial services receipt without MOUD (PSY)) in the United States (US). Methods In this retrospective cohort study, we analyzed data from the Merative™ MarketScan ® Multi-State Medicaid Databases 2016–2021 among postpartum women with OUD who did and did not initiate BUP during pregnancy. Our primary outcome was the receipt of prescribed highly-effective or effective contraception by 90 days postpartum. Highly-effective contraception was defined as female sterilization and long-acting reversible contraception [LARC]). Effective contraception was defined as oral contraceptive pills [OCPs], the contraceptive patch, ring, or injection. We used multivariable Poisson regression models, adjusting for sociodemographic and clinical characteristics, to measure the association of BUP (vs. PSY) on postpartum contraception utilization. Results Our sample consisted of 11,118 postpartum people with OUD. Among those, 3,443 initiated BUP and 7,675 received PSY. By 90 days postpartum, 22.4% ( n  = 2,487) of the cohort were prescribed contraception (21.5% PSY vs. 24.3% BUP). Among these participants, most received LARC (41.0%), followed by female sterilization (27.3%), the contraceptive injection (17.3%), pills (8.6%), ring (4.7%), and patch (1.0%), Compared to people engaged in PSY, BUP receipt was associated with a greater use of prescribed contraceptive use by 90 days postpartum (adjusted relative risk [aRR] = 1.17[1.07–1.28]), including a modestly greater use of the patch, ring, and pills, (aRR = 1.13[1.08–1.18]), but a modestly lesser use of injection contraception (aRR = 0.95[0.91–0.99]). There was no relationship observed between BUP and LARC use (aRR = 1.00[0.95–1.04]) and female sterilization (aRR = 1.01[0.98–1.06]). Conclusions Only 22% of pregnant people with OUD in our cohort used effective or highly-effective postpartum contraception. BUP receipt during pregnancy, relative to PSY, was associated with modestly greater use of prescribed effective contraceptive methods but was not associated with greater use of provider-administered contraceptive methods, such as the contraceptive injection, LARC and female sterilization.

Studies comparing the impact of the COVID-19 pandemic on diagnostic microbiology culture yields and antimicrobial resistance proportions in low-to-middle-income and high-income countries are lacking. A retrospective study using blood, respiratory, and urine microbiology data from a community hospital in India and two community hospitals (Hospitals A and B) in St. Louis, MO, USA was performed. We compared the proportion of cultures positive for selected multi-drug-resistant organisms (MDROs) listed on the WHO’s priority pathogen list both before the COVID-19 pandemic (January 2017–December 2019) and early in the COVID-19 pandemic (April 2020–October 2020). The proportion of blood cultures contaminated with coagulase-negative Staphylococcus (CONS) was significantly higher during the pandemic in all three hospitals. In the Indian hospital, the proportion of carbapenem-resistant (CR) Klebsiella pneumoniae in respiratory cultures was significantly higher during the pandemic period, as was the proportion of CR Escherichia coli in urine cultures. In the US hospitals, the proportion of methicillin-resistant Staphylococcus aureus in blood cultures was significantly higher during the pandemic period in Hospital A, while no significant increase in the proportion of Gram-negative MDROs was observed. Continuity of antimicrobial stewardship activities and better infection prevention measures are critical to optimize outcomes and minimize the burden of antimicrobial resistance among COVID-19 patients.

Purpose: Neurofibromatosis type 1 has been linked to several neurological conditions, including epilepsy, Parkinson disease, headache, multiple sclerosis, and sleep disturbances, predominantly through case reports and patient series that lack comparison groups. Our objective was to assess whether specific neurological conditions occur more frequently in individuals with neurofibromatosis type 1 versus those without neurofibromatosis type 1. Methods: We used the 2006–2010 MarketScan Commercial Claims and Encounters database to examine associations between neurological conditions and neurofibromatosis type 1. The neurofibromatosis type 1 group was identified through ≥2 International Classification of Diseases, Ninth Revision, Clinical Modification neurofibromatosis codes (237.70, 237.71) occurring ≥30 days apart or one inpatient neurofibromatosis code. A nonneurofibromatosis type 1 comparison group was frequency matched to the neurofibromatosis type 1 group on age and enrollment length at a 10:1 ratio. Unconditional logistic regression was employed to calculate adjusted odds ratios and 95% confidence intervals for associations between neurofibromatosis and neurological conditions. Results: Compared with the nonneurofibromatosis type 1 group ( n = 85,790), the neurofibromatosis type 1 group ( n = 8,579) had significantly higher odds of health insurance claims for epilepsy (odds ratio: 7.3; 95% confidence interval: 6.4–8.3), Parkinson disease (odds ratio: 3.1; 95% confidence interval: 1.3–7.5), headache (odds ratio: 2.9; 95% confidence interval: 2.6–3.1), multiple sclerosis (odds ratio: 1.9; 95% confidence interval: 1.2–2.9), and sleep disturbances/disorder (odds ratio: 1.4; 95% confidence interval: 1.2–3.6). Conclusion: This large study provides strong evidence for positive associations between several neurological conditions and neurofibromatosis type 1. Genet Med advance online publication 05 June 2014

Objective:To determine the relationship between severe acute respiratory syndrome coronavirus 2 infection, hospital-acquired infections (HAIs), and mortality.Design:Retrospective cohort.Setting:Three St. Louis, MO hospitals.Patients:Adults admitted ≥48 hours from January 1, 2017 to August 31, 2020.Methods:Hospital-acquired infections were defined as those occurring ≥48 hours after admission and were based on positive urine, respiratory, and blood cultures. Poisson interrupted time series compared mortality trajectory before (beginning January 1, 2017) and during the first 6 months of the pandemic. Multivariable logistic regression models were fitted to identify risk factors for mortality in patients with an HAI before and during the pandemic. A time-to-event analysis considered time to death and discharge by fitting Cox proportional hazards models.Results:Among 6,447 admissions with subsequent HAIs, patients were predominantly White (67.9%), with more females (50.9% vs 46.1%, P = .02), having slightly lower body mass index (28 vs 29, P = .001), and more having private insurance (50.6% vs 45.7%, P = .01) in the pre-pandemic period. In the pre-pandemic era, there were 1,000 (17.6%) patient deaths, whereas there were 160 deaths (21.3%, P = .01) during the pandemic. A total of 53 (42.1%) coronavirus disease 2019 (COVID-19) patients died having an HAI. Age and comorbidities increased the risk of death in patients with COVID-19 and an HAI. During the pandemic, Black patients with an HAI and COVID-19 were more likely to die than White patients with an HAI and COVID-19.Conclusions:In three Midwestern hospitals, patients with concurrent HAIs and COVID-19 were more likely to die if they were Black, elderly, and had certain chronic comorbidities.

To use interrupted time-series analyses to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infections (HAIs). We hypothesized that the pandemic would be associated with higher rates of HAIs after adjustment for confounders. We conducted a cross-sectional study of HAIs in 3 hospitals in Missouri from January 1, 2017, through August 31, 2020, using interrupted time-series analysis with 2 counterfactual scenarios. The study was conducted at 1 large quaternary-care referral hospital and 2 community hospitals. All adults ≥18 years of age hospitalized at a study hospital for ≥48 hours were included in the study. In total, 254,792 admissions for ≥48 hours occurred during the study period. The average age of these patients was 57.6 (±19.0) years, and 141,107 (55.6%) were female. At hospital 1, 78 CLABSIs, 33 CAUTIs, and 88 VAEs were documented during the pandemic period. Hospital 2 had 13 CLABSIs, 6 CAUTIs, and 17 VAEs. Hospital 3 recorded 11 CLABSIs, 8 CAUTIs, and 11 VAEs. Point estimates for hypothetical excess HAIs suggested an increase in all infection types across facilities, except for CLABSIs and CAUTIs at hospital 1 under the \"no pandemic\" scenario. The COVID-19 era was associated with increases in CLABSIs, CAUTIs, and VAEs at 3 hospitals in Missouri, with variations in significance by hospital and infection type. Continued vigilance in maintaining optimal infection prevention practices to minimize HAIs is warranted.

Abstract BACKGROUND Comparative efficacy of biologics is an important consideration when selecting therapies for Crohn’s disease (CD). While recent studies have focused on clinical remission, few studies have assessed the comparative efficacy of biologics in preventing penetrating disease (PD) complications of CD. The aim of our study was to compare the rates of penetrating complications (luminal and perianal) between biologics used as first-line therapies in CD. METHODS A propensity-score adjusted retrospective comparative effectiveness study was performed using IBM® MarketScan® Commercial Database (2006-2020). We included adults (≥18 years) with CD (≥3 administrative claims for CD [K50.*]) who initiated their first biologic (anti-tumor necrosis factor [anti-TNF], ustekinumab ([UST]) or vedolizumab [VDZ]). with ≥ 2 consecutive years of health insurance enrollment during study period (at least 1 year following index date). Patients with pre-existing luminal penetrating disease (LPD) or perianal penetrating disease (PPD) or prior biologic exposure were excluded using a minimum look-back period of 1 year. LPD was identified by ICD claims (537.4, 567.2X, 569.X, 593.82, 596.1, 619.1, K31.6, K65.X, K63.X, N82, N32.1) and PPD by a validated case definition. Patients were followed until a PD event and censored if a new biologic class was initiated, loss of medical coverage or study end. Cohorts were balanced by inverse probability of treatment weighting based on age, sex, Elixhauser comorbidity score, and prior CD surgery. Pairwise comparisons of biologic classes were performed by cox-proportional hazard models with medication exposure treated as a time-dependent variable based on a medication possession ratio of 0.8. RESULTS A total of 40693 patients with CD without prior penetrating disease (54.1% female, median age 39 years [IQR; 28-50]) initiated biologic therapy: 37839 (93.0%) anti-TNF, 1194 (3.0%) UST and 1660 (4.0%) VDZ. Penetrating complications developed in 8567 (21.1%) patients: 2,204 (5.4%) LPD and 7,474 (18.4%) PPD. Compared with no medication exposure, anti-TNFs were protective against composite (Figure 1, HR 0.91; 95% confidence interval (CI), 0.84 - 0.98, p = 0.013) and LPD (HR 0.59; CI, 0.50 - 0.69; p <.0001) but not PPD (HR, 0.99; CI, 0.91 - 1.07; p = 0.78). Neither VDZ nor UST were protective against composite, LPD or PPD. In pairwise comparisons, anti-TNF was significantly protective against composite (Figure 2, HR 0.92; CI, 0.85 – 0.99; P = 0.018) and LPD (HR 0.51; CI, 0.44 – 0.60; p <.0001) compared with VDZ and for LPD compared with UST (HR, 0.71; CI, 0.61 – 0.83, p <.0001). CONCLUSIONS Anti-TNF therapy was protective against developing LPD and may offer an advantage over VDZ and UST in preventing this disease complication. Further studies are needed to validate these findings and to determine potential reasons for these differences. Figure 1: Comparison of biologics in preventing the composite outcome of penetrating complications in patients with Crohn's disease. Figure 2: Comparison of anti-TNF versus vedolizumab in preventing composite outcome of penetrating complications in patients with Crohn's disease